Seizure 22 (2013) 80–82
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Case report
Chronic repetitive nonprogressive epilepsia partialis continua due to rheumatoid meningitis David Krysl a,*, Josef Zamecnik b, Ladislav Senolt c, Petr Marusic a a
Department of Neurology, 2nd Faculty of Medicine, Charles University in Prague, University Hospital Motol, Prague, Czech Republic Department of Pathology and Molecular Medicine, 2nd Faculty of Medicine, Charles University in Prague, University Hospital Motol, Prague, Czech Republic c Institute of Rheumatology and 1st Faculty of Medicine, Charles University in Prague, Czech Republic b
A R T I C L E I N F O
Article history: Received 9 August 2012 Received in revised form 11 October 2012 Accepted 13 October 2012 Keywords: Status epilepticus Rheumatoid arthritis Meningitis Magnetic resonance
1. Introduction Our case report describes a patient with recurrent episodes of epilepsia partialis continua (EPC) due to rheumatoid meningitis (RM). RM is an uncommon complication of rheumatoid arthritis (RA) and even rarer cause of seizures. It frequently occurs in patients with little or no systemic symptoms of RA, which may lead to a thorough and time-consuming differential diagnostic workup. To our knowledge, occurrence of EPC was not yet described in this condition. Brain biopsy analysis is mandatory for diagnosis; not only to give evidence of chronic lymphocytic fibroproductive leptomeningitis, but also to rule out leptomeningeal metastases and other causes of chronic meningitis (especially tuberculous meningitis and neurosarcoidosis). Although difficult to diagnose, RM has a favorable prognosis due to its rapid response to glucocorticoid therapy. Therefore, brain biopsy should not be delayed, especially in cases with characteristic magnetic resonance findings. 2. Case report Our case is a 62-year-old male with a ten-year history of rheumatoid arthritis (RA). The diagnosis of RA was based on the American College of Rheumatology 1987 revised classification criteria. The dominating features at disease onset were presence of
* Corresponding author at: University Hospital Motol, V Uvalu 84, 150 06 – Prague 5, Czech Republic. Tel.: +420 22443 6865. E-mail addresses:
[email protected],
[email protected] (D. Krysl).
symmetric arthritis of hand joints involving more than three joint areas and positivity of serum rheumatoid factor (RF). The disease was mild and initially treated with chloroquine for two years. Sustained drug-free clinical remission was achieved thereafter. Medical history of the patient was otherwise unremarkable. At the age of 60, he was admitted to a regional hospital due to recurrent episodes of epilepsia partialis continua (EPC) involving his right leg and subsequent spread to the right hemibody. After unsuccessful trial of benzodiazepines, the seizures were stopped with a load of phenytoin (PHT). Brain magnetic resonance imaging (MRI) showed increased T2 signal of the leptomeninges over the right frontal lobe as well as the medial part of the left hemisphere. In the latter region, gadolinium enhancement of the leptomeninges was seen (see Fig. 1A and B). T2 signal increase over the right leg motor and sensory area was primarily considered as a sign of luxury perfusion in the left anterior cerebral artery territory, and the etiology of EPC was presumed to be ischemic. One month later, the patient was referred to our institution due to another episode of EPC involving the right leg. Laboratory findings on admission showed markedly increased transaminase levels, which slowly normalized after PHT discontinuation. Followup MRI showed similar findings as the first examination. Magnetic resonance venography ruled out thrombosis of superior sagittal sinus. Cerebrospinal fluid (CSF) sample showed normal protein values (245 mg/l), no inflammatory cells and no oligoclonal bands (OCB). No atypical cells were reported from CSF cytoflowmetry. Polymerase chain reaction (PCR) for common viral pathogens was negative, as well as antibody tests for Lyme disease and syphilis. Chest X-ray was normal. Electroencephalography (EEG) demonstrated intermittent slow activity bilaterally in the frontotemporal regions, slightly more pronounced on the left side. Levetiracetam (LEV) was started. Gradual dose escalation of LEV was needed due to repeated seizures, including another episode of EPC in the right leg lasting several hours. Seizure freedom was finally achieved with LEV daily dose of 2250 mg. A whole-body 18F-fluorodeoxyglucose positron emision tomography combined with whole-body computed tomography (FDG-PET/CT) was performed, ruling out an occult neoplasm. However, hypermetabolism in several joints and lymph nodes was found, consistent with the diagnosis of RA with subclinical disease activity. Six month after symptom onset, a follow-up CSF analysis showed normal total protein (345 mg/l) and normal cell count.
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Fig. 1. Evolution of MRI changes in time. FLAIR sequence is shown in the upper row, the corresponding T1 gadolinium enhanced images in the lower row. (A and B, onset) Increased signal of sulci can be seen in the right frontal and especially left fronto-parietal cortex close to the midline and mild post-contrast enhancement within falx cerebri. (C and D, 24 months) Increased signal is now visible over both frontal cortices; mild post-contrast enhancement of falx cerebri can still be seen. (E and F, 30 months, following glucocorticoid treatment): resolution of signal changes and of gadolinium enhancement.
Isoelectric focusing demonstrated two OCB in the CSF (no bands were present in serum). At this stage, brain biopsy was planned. However, second follow-up MRI showed regression of signal changes and due to this finding, together with patient’s seizure freedom, the biopsy was deferred. After six months of clinical stabilization, the patient experienced another focal motor seizure with secondary generalization and LEV daily dose was increased to 3000 mg. Follow-up MRI (one year after symptom onset) showed progression of leptomeningeal T2 signal increase, namely over left parietal, but also over both frontal cortices (see Fig. 1C and D). Concurrently, the patient developed psychiatric symptoms including episodes of mania, confusion, and aggression. EEG ruled out nonconvulsive status epilepticus (SE). Another proposition for brain biopsy was declined by the patient. A third CSF sample was taken, showing mild increase of cell count (32 cells/3 ml, with 45% lymphocytes, 48% monocytes and 7% polymorphonuclear leucocytes). No OCB was found in the CSF or serum. PCR for Mycobacterium tuberculosis was negative. Western blott for well-characterized onconeural antibodies (anti-Hu, Yo, Ri, Ma, CV2, and amphiphysin) in the serum was negative, as well as follow-up serology of Lyme disease. The patient’s psychiatric symptoms improved after introduction of olanzapine and gradual switch from LEV to carbamazepine. Almost two years after the onset of symptoms, the patient consented to brain biopsy. A small sample of the leptomeninges with the adjacent cortex was taken from the right frontal lobe, guided by the signal changes on another follow-up MRI. Histopathologically, the leptomeninges revealed chronic fibroproductive inflammation with predominantly perivascular lymphocytic infiltration. To a lesser extent, the lymphocytic infiltration was observed also in the adjacent cortex with perivascular accentuation. Glial fibrillary acidic protein (GFAP) immunohistochemistry showed mild gliosis of the cortex (Fig. 2). No
granulomas, vascular changes or a tumor were observed in the biopsy. In the clinical context, the diagnosis of chronic rheumatoid meningitis (meningoencephalitis) was established. Glucocorticoid therapy was started (initial daily dose of prednisone 60 mg was followed by rapid tapering to a daily dose of 10 mg). Follow-up MRI showed almost complete regression of leptomeningeal signal changes (see Fig. 1E and F). The patient was clinically free of symptoms and reported less fatigue. Additional test for RF in the CSF was negative. The patient was referred to an outpatient rheumatology clinic. There were no clinical symptoms of joint inflammation, pain, tenderness or stiffness. Laboratory investigations revealed normal acute phase reactants; however, RF and anti-CCP antibodies were significantly elevated with titer 1:320 (cutt-off value 1:80) and 760 U/ml (normal range 0–25), respectively. Subsequent radiographic examination of the hands, wrist and feet showed erosions at both fifth metatarsophalangeal joints and periarticular osteoporosis of hands. Alternative systemic rheumatic diseases were excluded. Although the patient maintained drug-free clinical remission for several years, his RA relapsed while tapered to low-dose glucocorticoid treatment (5 mg prednisone daily). Nevertheless, the patient’s neurological and psychiatric status remained excellent allowing for successful gradual withdrawal of olanzapine. He is still treated with carbamazepine and is seizure free for more than one year. 3. Discussion Rheumatoid meningitis (RM) is a rare condition and a very rare cause of seizures.1,2 Epileptic seizures occur in approximately 21% of patients with RM, more frequently in those with predominant leptomeningeal involvement.1Although mental status change was
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Fig. 2. Histopathology. (A) Hematoxylin–eosin stain showing marked fibrous thickening of leptomeninges (delineated by arrows). (B) The lymphocytic infiltration was present both in the leptomeninges and in the perivascular regions of the adjacent cortex (arrows). (C) CD3 immunohistochemistry demonstrating that the inflammatory infiltrate consists predominantly of T lymphocytes. (D) Mild gliosis of the adjacent cortex was evident in GFAP immunohistochemistry. Scale bar = 80 mm (A) and 50 mm (B–D).
reported as the most common symptom of RM,1 it is not clear how many cases are attributable to nonconvulsive SE. In our patient, the episode of psychiatric disturbance was not caused by non-convulsive SE. Apart from the direct effect of leptomeningeal involvement, it could have been caused by antiepileptic medication (LEV). Other frequent symptoms of RM include hemiparesis, cranial neuropathy and headache. Atypical syndromes, such as progressive supranuclear palsy-like clinical picture with vertical gaze palsy, dementia and frequent falls have been reported.3 MRI findings include regional T2 signal increase of subarachnoid space and mild leptomeningeal gadolinium enhancement.4 Although characteristic, these findings are not specific for RM. CSF findings in RM are normal, or show unspecific elevation of protein or mild increase of cells. Usefulness of measuring RF in the CSF was suggested by some authors,5 however, RF was not detected in the CSF in our case, despite using a sample taken in the highly active stage of the disease prior to corticosteroid treatment. The case shows that RM may occur in patients with RA who have mild or no systemic inflammatory involvement. This may cause diagnostic difficulties. We may speculate that in our patient, low grade subclinical joint inflammation observed on FDG-PET/CT may have contributed to the development RM. The neuropathological evidence of chronic lymphocytic fibroproductive leptomeningitis (and, to a lesser extent, lymphocytic infiltration of the adjacent brain cortex) in the context of RA will lead to correct diagnosis when all other causes of chronic meningitis are excluded (especially tuberculous meningitis, neurosarcoidosis and leptomeningeal metastases). Drug-induced aseptic meningitis (i.e. following ibuprofen treatment) remains an important differential diagnostic option. Recently, cases of RM induced by TNF-a antagonist adalimumab have also been described.5 No guidelines are available for the treatment of RM. However, most reports showed efficacy of glucocorticoids.1,6–8 Promising results with rituximab have also been published.9
In summary, RM is an important consideration in patient with RA and de novo onset of seizures or SE, especially if characteristic MRI findings are present. Due to multiple differential diagnostic considerations, a brain biopsy analysis is mandatory for diagnosis. Because of rapid response of the disease to glucocorticoids, biopsy should not be delayed.
Conflict of interest None of the authors has any conflict of interest to disclose.
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